LESSON 1: Vision, Mission, Core Values, and Objectives of the Institutions

Educational Institution

An educational institution is a place where learners of different ages gain education.

Education is based on an age grade system from preschool, primary, intermediate, and
secondary level (junior and senior high school), to tertiary level (colleges and universities).
Educational institutions carry out educational activities that engage students with various
learning environments and spaces.

However, not all types of educational institutions are structured and formalized. While
established educational institutions follow a well-defined curriculum, some learning
environments are spontaneous and have no fixed timetables.

There are two types of education: formal and informal.

Formal education deals with the conventional classroom setup where structured
methods of learning are administered in educational institutions. Government recognition in
terms of the curricular offering that predetermines the books and materials to be used for
instruction is necessary to establish standards in the academic community. Faculty and
instructors follow the curricula set by a technical committee appointed by the government.
Formal education starts at around age 4 from preschool up to higher education. It takes place in
a stipulated period in which learners complete each level by acquiring the required
competencies in preparation for higher learning

Informal education, on the other hand, is anything learned independently outside the
conventional classroom setup. It is not restricted to a certain location and is usually integrated
with the surroundings such as the home, cultural setting, and even in formal education
institutions. Informal education involves the students' behavior skills through interaction and
exploration on a daily basis as well as the teachers traits that vary based on their expertise,
skills, and experience.

Vision and Mission Statement

Vision Statement

A vision statement conveys the desired end of an academic institution. It is usually a

one-sentence statement that describes the distinct and motivating long-term desired
transformation resulting from institutional programs. The vision statement should be clear,
memorable, and concise with an average length of 14 words. The shortest contains only three
words-such as "Equality for Everyone, a human rights campaign-while the longest may contain
up to 26 words such as "A World in which every person enjoys all of the human rights enshrined
in the Universal Declaration of Human Rights and other international human rights instruments"
of Amnesty International.
Mission Statement

A mission statement is a one-sentence statement relating the intention of an

institution's existence. This communicates what you do or who you do this for. The mission
statement must be clear by using simple language with an average of 5 to 20 words. Examples
include "Spreading Ideas" by TED, "The increase and diffusion of knowledge" by the
Smithsonian, and "Seeking to put Gods love into action, Habitat for Humanity brings people
together to build homes, community and hope" by Habitat for Humanity.

Comparison between a vision statement and a mission statement

Vision Statement Mission Statement

It inspires to give the best
It defines the key measure of
Function shapes your understanding of
the institution‟s success.
why you are in the institution.
When do you want to reach
success? What do we do today?
Developing Statement Where do we want to go For whom do we do it?
forward? Why do we do what we do?
How do we want to do it?
Talks about the present
Time Talks about the future
leading to the future
What makes you different?
Where do you aim to be?
Question How will you get where you
Where do you want to be?
want to be?

Value Statement

A value statement, or the core values, is a list of fundamental doctrines that guide and
direct the educational institution. This sets the moral direction of the institution and its academic
community that guides decision-making and provides a yardstick against any action. The core
values shape the standard structure that is shared and acted upon by the academic community.

In developing an institution's value statement, consider the following questions:

 What values are distinct to our educational institution?

 What values should direct our institution?

For an educational institution to have a useful value statement, its values must be
incorporated in all levels of the institution to give direction to its engagements, viewpoints, and
decision-making processes.
Objectives

Educational objectives, or goals, are short statements that learners should achieve
within or at the end of the course or lesson. When setting the objectives, curriculum developers
must think of the SMART criteria; that is, objectives must be Specific, Measurable, Attainable,
Realistic and Time bound.

Below is a list of educational objectives set by the Commission on Higher Education

(CHED) through CHED Memorandum Order No. 14, series of 2006 on "Policies, Standards, and
Guidelines for Medical Technology Education."

The Medical Technology Education aims to:

1. Develop the knowledge, attitudes, and skills in the performance of clinical laboratory
procedures needed to help the physician in the proper diagnosis, treatment, prognosis,
and prevention of diseases;
2. Develop skills in critical and analytical thinking to advance knowledge in Medical
Technology/Clinical Laboratory Science and contribute to the challenges of the
profession;
3. Develop leadership skills and to promote competence and excellence; and
Uphold moral and ethical values in the service of society and in the practice of the profession.

Key Points to Remember

 An educational institution carries out educational activities that engage students with
various learning environments and spaces.
 Education is based on an age grade system from preschool, primary, intermediate, and
secondary level to the tertiary level.
 A vision statement is the desired end of an academic institution. It is usually a one-
sentence statement that describes the distinct and motivating long-term desired
transformation resulting from institutional programs.
 A mission statement is a one-sentence statement relating the intention of an institution‟s
existence.
 A value statement, or core values, is a list of fundamental doctrines that guide and direct
the educational institution.
 An educational objective is a short statement that a learner should achieve within or at
the end of the course or lesson.

LESSON 2: Health System

Health system is "the combination of resources, organization, financing, and

management that culminate in the delivery of health services to the population (Roemer. 1991)."
This system consists of many parts such as the community, department or ministries of health,
health care providers, health service organizations, pharmaceutical companies, health financing
bodies, and other organizations related to the health sector. Each plays a role in the system
such as governance, health service provision, and financing and managing resources.

In the World Health Report (WHO, 2000), health system is defined as all the
organizations, institutions, resources, and people whose primary purpose is to improve health.
Thus, a well-performing health system provides direct health-improving activities whether in
personal health care, public health services, or intersectoral initiatives, to achieve high health
equity.

Goals and Functions of a Health System

The World Health Organization (WHO) identifies three (3) main goals of a health system:

1. Improving the health of populations

Improving the health of the population is the overarching goal of a health system.
Health status should thus be measured over the entire population and across different
socioeconomic groups Populations must be protected from existing and emerging health
risks. Intensive preparations for resilience to impending but still unknown health risks
must be executed to ensure the safety of populations. Health systems should strive for
equity in health by minimizing inequitable disparities which may be caused by certain
factors such as income, ethnicity, occupation, gender, geographic location, and sexual
orientation, among others. There are significant variations in health outcomes across the
world, within regions and within countries. Countries and regions with relatively simili
socioeconomic status may have quite disparate health outcomes. The way health
systems are organized contributes to this disparity. These disparities are most effectively
reduced when they are recognized and their minimization becomes an explicit national
goal.
2. Improving the responsiveness of the health system
Responsiveness refers to providing satisfactory health services and engaging
people as active partners. It embodies the values of respectfulness, dignity,
confidentiality, autonomy, quality, and timeliness in the delivery of health services.
Health systems also have an obligation to respond to the legitimate non-health needs
and expectations of populations. Responsive health systems maximize people‟s
autonomy and control, allowing them to make choices and placing them at the center of
the health system.
3. Providing fair health financing
An ideal health system provides social and financial risk protection in health.
Thus, all health systems must be adequately funded to provide essential services to all
citizens. WHO defines a fairly financed health system as one that does not deter
individuals from receiving needed care due to payments required at the time of service,
and one in which each individual pays approximately the same percentage of their
income for needed services. A health financing system that dissuades people from
seeking needed services for impoverished individuals and families worsens health
outcomes.
The four (4) vital health system functions are:

1. Health service provision

The most visible product of the health system is public and private health service
provision. A health service is any service, not limited to clinical services, aimed at
improving the health of populations. Preventive measures as well as promotion of a
healthy way of living to avoid illnesses also form part of the best systems. Thus, the
system has to perform a wide range of activities to cater to these various demands.
2. Health service inputs
Health service inputs, or managing resources, means generating the essential
physical resources for the delivery of health services which include medications, human
resources, and medical equipment. Resources such as trained doctors and medical staff
and supply of medications often take time to be produced; hence, the health system
policymakers have to respond and use the available resources to address short-term
population needs.
3. Stewardship
Stewardship, or the overall system oversight, is the main responsibility of the
government. This function sets the direction, context, and policy framework for the
overall health system.
The core of the stewardship function includes:
a. Identifying health priorities for allocation of public resources;
b. Identifying an institutional framework;
c. Coordinating activities with other systems related to external health care;
d. Analyzing health priorities and resource generation trends and their
implications; and
e. Generating appropriate data for effective decision-making and policymaking
on health matters.
4. Health financing
Health system financing includes raising and pooling resources to pay for health
services.
a. Revenue collection
Revenue is earned from payments for health care services. The
mechanisms for revenue collection include general taxation, direct household
out-of-pocket expenditures mandatory payroll contributions, mandatory or
voluntary risk-rated contributions, donor financing, and other forms of
personal savings.
Each source of health financing is associated with a specific manner of
organizing and pooling of funds and purchasing services. Public health
systems rely on general taxation for its financing, while social security
organizations are funded through the mandatory payroll contributions from
workers and employers.
b. Risk pooling
Financial risk pooling is a form of risk management which aims to spread
financial risks from an individual to all pool members. It is considered a core
function of health insurance companies. This mechanism prevents outright
 payment for health services which discourages patients belonging to the poor
sector from seeking health Participation in effective risk pooling helps families
from financial losses due to health shocks, thus ensuring financial protection.
Each country has its own approach to managing its financial risk to
finance its health care system. Multiple and fragmented forms of risk pooling
arrangements exist in most developing countries. Most high-income countries
follow one of the two main models: the Bismarck model and the Beveridge
model.
 Bismarck Model (Bismarck's Law on Health Insurance of 1883)
This model is named after the Prussian Chancellor, Otto von
Bismarck, known for inventing the welfare state in the 19th century as
part of the unification of Germany. The Bismarck model uses an
insurance system where the sickness fund finances both the employers
and the employees through payroll deduction. But unlike the US
insurance industry, the Bismarck-type health insurance plan covers
everybody, thus collecting no profit. This is considered a multi-payer
model with tight regulation giving the government the cost-control clout.
This model is widely used in Germany, France, Belgium, Netherlands,
Japan, Switzerland, and, to a degree, in Latin America.
 Beveridge Model (Beveridge Report or the Social Insurance and Allied
Services of 1942)
This model is named after William Beveridge, the social reformer
responsible for designing Britain's Social Security System and the
National Health Service. In the Beveridge model, health care is provided
and funded by the government through tax payments. The government
owns many, but not all, hospitals and clinics in the country. Doctors may
be government or private employees who collect their professional fees
from the government. This results in low cost per capita since the
government controls the health care services. Countries using the
Beveridge plan include Hong Kong. Great Britain, Spain, most of
Scandinavia, New Zealand, and Cuba. The Cuban government, for
instance, uses total government control.
c. Strategic purchasing
In strategic purchasing, risk-pooling organizations use collected funds
and pooled financial resources to finance health care services for the
members. The purchaser defines the substantial part of the health provider's
external incentives to develop the provider user interaction and the health
service delivery models.
WHO Health System Framework

In its World Health Report 2000, WHO released a single framework (Figure 2.1) with six
clearly defined building blocks and priorities which are necessary in strengthening health
systems and improving the overall health outcomes.

Figure 2.1 WHO Health Systems Framework

(Figure by World Health Organization (2007), licensed under CC BY-SA 4.0)

One building block is service delivery which refers to the timely delivery of quality and
cost-effective personal and non-personal health services. Another is health workforce which
includes individuals and groups working towards the achievement of the best health outcomes
by being responsive, fair, and efficient. The number of staff should be sufficient and fairly
distributed to ensure competency, responsiveness, and productivity. Information (health
information system) which analyzes disseminates and uses reliable and relevant information on
health status, determinants, and systems performance is also a valuable building block. Another
important building block is that of health products, vaccines, and technologies which are
made accessible through uninterrupted supply, well-managed pharmaceutical services, and
education on proper use of medication. Financing (health financing system) is a building block
which takes care of the funding for health care services to guarantee that people can use health
services when needed without fear of having not enough resources to pay for them. Lastly,
leadership and governance involves the task of ensuring effective stewardship of the entire
health system. This building block also covers the monitoring of the accountability of private and
public health agencies, proper system design, and appropriate regulation of health systems.
The Philippine Health System

Historical Background

The health reform initiatives carried out over the years in the Philippines were primarily
focused on these areas of concern: health service delivery, health regulation, and health
financing. These health reforms aimed at addressing issues such as poor accessibility, inequity,
and inefficiency of the Philippine health system.

1. 1979: Adoption of Primary Health Care Strategy (LOI 949) - promoted

participatory management of the local health care system
2. 1982: Reorganization of DOH (EO 851) - integrated the components of health care
delivery in. its field operations
3. 1988: The Generics Act (RA 6675) - ushered the writing of prescriptions using the
generic name of the drug
4. 1991: Local Government Code (RA 7160) - transferred the responsibility of
providing health service to the local government units
5. 1995: National Health Insurance Act (RA 7875) - instituted a national health
insurance mechanism for financial protection with priority given to the poor
6. 1999: Health Sector Reform Agenda - ordered the major organizational
restructuring of the DOH to improve the way health care is delivered, regulated, and
financed
7. 2005: FOURmula One (F1) for Health - adopted an operational framework to
undertake reforms with speed, precision, and effective coordination and to improve
the Philippine health system
8. 2008: Universally Accessible Cheaper and Quality Medicines Act (RA 9502) -
promoted and ensured access to affordable quality drugs and medicines for all
9. 2010: Kalusugan Pangkalahatan or Universal Health Care (AO 2010-0036) -
provided universal health coverage and access to quality health care for all Filipinos

Leadership and Governance

The Department of Health (DOH) is mandated to provide the appropriate direction for the
nation's health care industry. Its other tasks include (1) the development of plans, guidelines
and standards for the health sector. (2) technical assistance; (3) capacity building: (4) advisory
services for disease prevention: and (5) control of medical supplies and vaccines.

DOH coordinates its national health programs through the local government units
(LGUS), LGUs take care of their own health services and are given autonomy under the Local
Government Code (1.GC) 1991 (R.A. 7160). 78 provincial governors, 138 city mayors, 1.496
municipal mayors, and 42,025 barangay chairpersons compose the local government units of
the country (NSCB. 2010).

In terms of administration, LGUs are grouped into 17 regions Although they operate in a
decentralized system, LGUS are under the supervision of the DOH regional health offices. The
provincial government is tasked to provide health services through provincial and district
hospitals. The city and municipal governments rely on public health and primary health care
centers for their primary care. (For a detailed organizational structure of the Philippine health
sector, see The Philippines Health System Review (2011) published in Health System in
Transition, vol. 1, no. 2.)

DOH is duty-bound to:

1. develop policies and programs for the health sector,

2. provide technical assistance to its partners,
3. encourage performance of the partners in the priority health programs,
4. develop and enforce policies and standards,
5. design programs for large segments of the population, and
6. provide specialized and tertiary level care.

Under the decentralized or devolved structure, the state is represented by national

offices and LGUs, with provincial, city, municipal, and barangay or village offices. DOH, LGUs
and the private sector participate, cooperate and collaborate in the care of the population.
Before devolution, the national health system consisted of a three-tiered system under the direct
control of the DOH: (1) the tertiary hospitals at the national and regional levels; (2) the provincial
and district hospitals and city and municipal health centers; and (3) the barangay (village) health
centers.

With the enactment of the LGC of 1991, the government health system now consists of
basic health services-including health promotion and preventive units- provided by cities and
municipalities provincial and province-run district hospitals of varying capacities, and mostly
tertiary medical specialty hospitals, and a number of re-nationalized provincial hospitals
managed by DOH.
Directions of the Philippine Health Sector

1. The Philippine Health Agenda 2016-2022 (DOH Administrative Order 2016-0038)

This agenda adopts the slogan "All for Health Towards Health For All as the rallying
point for vision of a Healthy Philippines by 2020. It expanded the scope of the Universal
Health Care (UHC directions, particularly through a whole-of-government approach. With
this agenda, the health system guarantees:
a. population- and individual-level interventions for all life stages that promote health
and wellness, prevent and treat the triple burden of disease, delay complications,
rehabilitation, and provide palliation for both the well and the sick;
b. access to health interventions through functional service delivery networks (SDNs);
and
c. financial freedom when accessing these interventions through Universal Health
Insurance.
2. The Philippine Development Plan 2017-2022
This is the first of the four key medium-term plans to translate the vision of a "matatag
maginhawa, at panatag na buhay" for the Filipinos and the country.
3. NEDA AmBisyon Natin 2040
A product of the Philippine Development Plan 2017-2022, this collective long-term plan
envisions better life for the Filipinos and the country in the next 25 years by formulating
policies and implementing programs and projects to attain this AmBisyon. This plan
focuses on four areas: building a prosperous, predominantly middle-class society where no
one is poor; promoting a long and healthy life; becoming smarter and more innovative, and
building a high-trust society.
4. Sustainable Development Goals 2030
Also known as the 2030 Agenda, this compilation of 17 global development goals targets
to end poverty, fight inequality and injustice, and confront issues involving climate change.

Key Points to Remember

 Health system combines resources, organization, financing, and management to deliver

health services to the population. According to the World Health Report (WHO, 2000),
health system is defined as "all the organizations, institutions, resources, and people
whose primary purpose is to improve health."
 The primary goals of a health system are improved health outcomes (attaining the best
average level health care for the entire population by minimizing disparities), more
responsive health system (meeting the people's expectations of and satisfaction from
health service delivery), and more equitable health care financing (protecting each
individual from financial risks).
 The four functions of the health system are health services provision (for appropriate and
cost-effective health delivery); health service inputs (for generating human resources,
technology, and capital); health financing (by revenue collection, risk pooling, and
strategic purchasing); and stewardship and initiatives (to strengthen governance,
accountability, and responsiveness).
  A health system can be analyzed in its totality by using a framework consisting of six
building blocks, i.e., leadership and governance, health financing, health workforce,
health products, vaccines, and technologies, health information, and service delivery.
 The Department of Health (DOH) is the lead agency for Philippine health care.
According to its mandate (E.O. No. 119, Sec. 3), the DOH shall be responsible for the (1)
formulation and development of national health policies, guidelines, standards, and
manual of operations for health services and programs; (2) issuance of rules and
regulations, licenses, and accreditations; (3) promulgation of national health standards,
goals, priorities, and indicators; and (4) development of special health programs and
projects, and advocacy for legislation on health policies and programs.

LESSON 3: Primary Health Care and the Philippine Health Care Delivery System

Health Care

According to the Alma-Ata Declaration 1978, health is a fundamental human right. It

states that the most important global goal is for humans to reach the optimal level of their health;
this requires nut the action of the health sector but the collaboration among other sectors such
as those in the social and economic sectors.

Meanwhile, a common concern of many countries, including both developed and

developing on is the gross inequality in the people's health status which is not socially,
economically, and politic acceptable. Thus, the government of each country has the duty and
responsibility to institute adequate measures to promote and protect its people's health, and
thus achieve a better quality of life.

For better understanding, the following concepts under health care are defined (as cited
in DeDios, n.d.):

1. Health care system is defined by Miller & Keane (1987) as “an organized plan of
health service.”
2. Health care delivery, as defined by Williams & Tungpalan (1981), is “the rendering
of health care services to the people.”
3. Health care delivery system, also as defined by Williams & Tungpalan (1981), is
“the network of health facilities and personnel which carries out the task of rendering
health care to the people.”

Primary Health Care

As cited by WHO, the Alma-Ata Declaration defines primary health care as important
health care derived from scientifically sound and socially acceptable methods. It must be
universally accessible to al individuals and is based on what the community and country can
provide.
 As an approach the primary health care (PHC) deals with social policy which targets
health equity. PHC has the essential elements and objectives that ensure attainable better
health services for all.

The ultimate goal of primary health care is better health for all. WHO has identified five
key elements to achieve this goal. These are

1. universal coverage to reduce exclusion and social disparities in health,

2. service delivery organized around people's needs and expectations,
3. public policy that integrates health into all sectors,
4. leadership that enhances collaborative models of policy dialogue, and
5. increased stakeholder participation.

Essential Elements of Primary Health Care

Below are the eight (8) elements of primary health care:

1. Education concerning prevailing health problems and the methods of identifying,

preventing, controlling them
2. Locally endemic disease prevention and control
3. Expanded program of immunization against major infectious diseases
4. Maternal and child health care including family planning
5. Essential drugs arrangement
6. Nutritional food supplement, an adequate supply of safe and basic nutrition
7. Treatment of communicable and non-communicable disease and promotion of
mental health
8. Safe water and sanitation

Other elements of primary health care include:

1. Expanded options of immunization

2. Reproductive health needs
3. Provision of essential technologies for health
4. Health promotion
5. Prevention and control of non-communicable diseases
6. Food safety and provision of selected food supplements

Principles of Primary Health Care

A conceptual shift in health care calls attention to the fact that primary health care should
be integrated, and its principles guide the functions of the system as a whole. Having a systems
perspective bridges the conflict between primary health care as a distinguished level of care and
as a holistic approach to the provision of health services.
 The health system should also consider the principles of the Alma-Ata Declaration and
other intersectoral approaches. It should cover broader health issues of populations while
reinforcing public health functions. It should come up with programs that provide care and
prevent diseases and provision for services especially for the poor and marginalized groups.
Finally, it should be able to monitor programs for continuous improvement.

The basic objectives to launch and sustain primary health care as part of the
comprehensive health system are as follows:

1. Improve the level of health care of the community

2. Promote favorable population growth structure
3. Reduce the morbidity and mortality rates especially among infants and children
4. Reduce prevalence of preventable, communicable, and other diseases
5. Improve basic sanitation
6. Extend essential health services especially to the underserved sectors
7. Develop the capability of the community to become self-reliant
8. Encourage the contribution of other sectors to the social and economic
development of the community
9. Provide equitable distribution of health care
10. Ensure community participation and monitor adequacy and distribution of health
worker are supported locally and at the referral levels
11. Recognize that the formal health sector needs other sectors in the promotion of
health (multi-sectoral approach)
12. Use the appropriate technology which are accessible, feasible, affordable, and
culturally acceptable to the community

Management of Primary Health Care

Health care managers usually carry out the following functions in the process of
management:
1. Planning - This means setting priorities and determining performance targets.
Managers are usually required to set a direction and determine what needs to be
accomplished.
2. Organizing - This refers to designing the organization or the specific division, unit, or
service for which the manager is responsible. Furthermore, it means designating
reporting relationship and intentional patterns of interaction, determining positions
and teamwork assignments, distributing authority and responsibility.
3. Staffing - This function refers to acquiring and retaining human resources, and
developing and maintaining the workforce through various strategies and tactics.
4. Controlling - This function refers to monitoring staff activities and performance and
taking the appropriate actions for corrective actions to increase performance.
5. Directing - This focuses on initiating action in the organization through the effective
leadership motivation, and communication of managers.
 Below are the management principles in relation to organizing:

1. Authority, responsibility, and accountability

a. Authority refers to the formal and legitimate right of a manager to issue orders,
make decisions, and allocate resources to achieve desired outcomes of the
organization.
b. Responsibility is the duty of the employee to perform the assigned tasks and
activities.
c. Accountability means reporting and justification of task outcomes to higher
management by those people with authority.
2. Types of authority
a. Line authority managers issue orders to their subordinates and are also
responsible for the results.
b. Functional authority is for managers that have power only over a specific set of
activities.
c. Staff authority is given to specialists in their areas of expertise. The staff
manager simply advises, recommends, and counsels.
3. Centralization, decentralization, and formalization
a. Centralization refers to the concentration of planning and decision-making to the
top of the organization.
b. Decentralization refers to the delegation of planning and decision-making to the
lower branches of the organization.
c. Formalization refers to a written documentation provided for the direct control of
the employees.
4. Staffing
As regards to the process of staffing, here is the list of functions of the manager:
a. Assign individuals to respective positions identified in the management plan
b. Assess required competencies through
 identification of the key result areas (KRAS) per major activity
 determination of the competencies and qualifications
c. Recruit qualified personnel
d. Improve existing services and programs by
 reviewing and adjusting the requirements accordingly
 matching the competency requirements vis-à-vis the responsible
personnel assigned to the activity

The Philippine Health Care System

According to Dizon (1977), the Philippine health care system is “a complex set of
organizations interacting to provide an array of health services.” It has progressed due to
challenges encountered over time. In 1991, the local government units (LGUS) took over the
management of health service delivery but the issue of fragmentation has not been absolutely
addressed. Health workforce has to deal with the pressing issues of underemployed workers,
limited resources, and unequal distribution. Meanwhile, the private sector which is said to
comprise 50% of the overall health system is strongly involved in improving the delivery of
health services, but the government's power to regulate should be optimized.

The Department of Health Mandate

As specified in Executive Order No. 119. Sec. 3, the Ministry of Health (now Department
of Health (DOH)) has the responsibility to create, plan, implement, and systematize national
health policies, advocacies, and programs. Its primary function is to promote, protect and
preserve or restore people's health by giving health services and by monitoring and motivating
health service providers. Moreover, it is responsible for the issuance of health-related licenses
and accreditations and disseminating information about national health indicators.

Vision

DOH vision by 2030 states

A global leader for attaining better health outcomes, competitive and responsible health
care system, and equitable health financing

Mission

DOH mission states

To guarantee equitable, sustainable and quality health for all Filipinos, especially lead
the quest for excellence in health

Levels of Health Care Facilities

Below are the levels of health care facilities according to Williams & Tungpalan (as cited
in DeDios, n.d.):

1. Primary Level of Health Care Facilities

The primary level of health care facilities refers to the following:
a. Units operated by the DOH which include the rural health units, their respective
sub-centers chest clinics, malaria eradication units, and schistosomiasis control
units;
b. Puericulture center operated by the League of Puericulture Centers;
c. Units operated by the Philippine Tuberculosis Society such as the tuberculosis
clinics and hospitals;
d. Clinics operated by the Philippine Medical Association;
e. Clinics operated by large industrial firms for their employees;
f. Health centers and community hospitals Commission, and operated by the
Philippine Medical Care Commission; and
 g. Other health facilities operated by voluntary religious and civic groups.
2. Secondary Level of Health Care Facilities
The secondary level of health care facilities includes the smaller and non-
departmentalized hospitals. These are emergency and regional hospitals where
adequate treatments are offered for patients with symptomatic stages of diseases.
3. Tertiary Level of Health Care Facilities
Included in the tertiary level are specialized national hospitals which offer highly
technological and sophisticated services. Patients who are afflicted with life-
threatening diseases requiring highly technical and specialized knowledge, facilities,
and personnel are treated here.

Levels of Primary Health Care Workers

1. Grassroot or Village Health Workers

a. They are the initial links of the community to health care.
b. They provide preventive health care measures and simple curatives to promote a
healthy environment.
c. They encourage programs/activities such as food production programs to improve
the socio-economic level of the community.
d. They are the volunteers, community health workers, or traditional birth attendants.
2. Intermediate Level Health Workers
a. They are the first source of professional health care.
b. They attend to health problems which are already beyond the competence of the
village workers.
c. They provide supervision, training, supplies, and services that provide support to
front-line health workers.
d. They are medical practitioners, nurses, and midwives.
3. First-Line Hospital Personnel
a. When hospitalization is required, they serve as the backup health service providers.
b. The intermediate level health workers or village health workers are in close contact
with them.
c. They are the physicians with specialty, nurses, dentist, pharmacists, and other health
professionals.

The categories of health workers are affected by certain factors such as

1. the availability of health manpower resources,

2. the presence of health care concerns and needs of the locality, and
3. the issue of financial and political feasibility.

Key Points to Remember

 Health is a fundamental human right as cited in the Alma-Ata Declaration of 1978.

 Reaching the highest possible level of health is important worldwide.
  Primary health care (PHC) is essential health care made universally accessible through
full participation of health care providers and at a cost that the community and the
country can afford.
 The ultimate goal of primary health care is better health for all. The principles of primary
health care should guide the functions of the system as a whole.
 Management of primary health care includes planning, organizing, staffing, controlling,
and directing
 Health care facilities are categorized into primary, secondary, and tertiary levels. Primary
health care workers are categorized as grassroot or village health workers, intermediate
level health workers, and first-line hospital personnel.
 The Philippine health care system has progressed due to many challenges through time.
The private sector has been strongly engaged but government regulation should be
optimized.
 The primary function of the Department of Health (then Ministry of Health) indicated in
EO no. 119 is to promote, protect, preserve, or restore people's health by giving health
services and monitoring health service providers.

LESSON 4: Overview of Health Informatics

Health Information Technology

The dawn of the information age has resulted in the generation of huge amounts of
routine data, particularly in health care, which can become perplexing to process and analyze.
This is the challenge for health Informatics--to make sense of large amounts of data while
ensuring that the processes are valid and secure.

The transition from a manual to a more advanced health information system is an

overarching issue for providers of health care managers, policymakers, researchers, and
patients alike. While there are benefits, there are also undeniable disadvantages. One
innovation that manages health information better service delivery is health information
technology.

Rouse (2016) defines health Information technology (HIT) as "the area of IT involving
the design development, creation, use, and maintenance of information systems for the health
care industry. Automated and interoperable health care information systems are expected to
improve medical care, lower costs, increase efficiency, reduce error, and improve patient
satisfaction while also optimizing reimbursement for ambulatory and inpatient health care
providers.”

Health information technology vows to provide innovation to health care delivery and
connection among users and stakeholders in the e-health market. Systems such as electronic
health records, decision support systems, and personal health records are promising and are
becoming widely deployed worldwide (Kushniruk & Borycki, 2017).
Health Care Software Systems

Rouse (2016) enumerates the following types of health information technology:

An electronic health record (EHR) is also called an electronic medical record

(EMR). It is one of the fundamental components of health information technology
infrastructure EHR is the patient's official health record in digital form and this
information is shared across multiple health care providers and agencies. The other key
elements are the personal health record (PHR) and the health information exchange
(HIE). A PHR 5 person's self-maintained health record while the HIE is the health data
clearinghouse which is comprised of health care organizations with interoperability pact
to share data among their health information technology systems.

In the United States, since the inception of the HITECH Act of 2009, the use and
implementation of EHR systems have increased dramatically. Hospitals and physicians
using the government-certified EHR systems meet the meaningful use criteria and are
qualified to receive incentives. The said criteria is regulated under the Office of the
National Coordinator (ONC) for health IT which certifies approved IT technology use
under the federal reimbursement program and Centers for Medicare & Medicaid
Services (CMMS). However, meaningful use is changing due to the Medicare Access
and Children's Health Insurance Plan Reauthorization Act (MACRA) which is a law on
value-based reimbursement system passed by the US Congress in 2015.

There are two widely used types of health information technology, the picture
archiving and communication systems (PACS) and vendor neutral archives (VNA).
These two help manage and store the patients' medical images.

PACS and VNAs integrate radiology into the main hospital workflow. Radiology
used to be the primary repository for medical images. Presently, other specialties such
as cardiology and neurology are also among the large-scale producers of clinical images
VNAs can also be installed for the purpose of merging stored imaging data from various
departments into a multi-facility health care system.

Health Information Ecosystem

The Healthcare Information and Management Systems Society (2017) defines a health
interoperability ecosystem as a composition of individuals, systems, and processes that share,
exchange, and access all forms of health information, including discrete, narrative, and
multimedia. Individuals, patients, providers, hospital/health systems, researchers, payors,
suppliers, and systems are potential stakeholders within such an ecosystem. Each is involved in
the creation, exchange, and use of health information and/or data.

An efficient health interoperability ecosystem provides an information infrastructure that

uses technical standards, policies, and protocols to enable seamless and secure capture,
discovery, exchange, and utilization of health information.

Health Informatics in the Cloud

The role of cloud technology is undeniably significant in our everyday lives. Currently, 83
percent of health care organizations are making use of cloud-based applications, and it is
changing the landscape of the health care system and health informatics. However, both
benefits and threats exist (University of Illinois, 2014).

Advantages of Cloud Technology

1. Integrated and Efficient Patient Care

Cloud technology offers a single access point for patient information which allows
multiple doctors to review laboratory results or notes on patients. Physicians can spend
more time deciding and performing patient treatment instead of waiting for information
from different departments.
2. Better Management of Data
The accumulation of electronic health records will allow more meaningful data
mining that can better assess the health of the general public. More data can mean more
opportunities to identify trends in diseases and crises.

Disadvantages of Cloud Technology

1. Potential Risks to Personal Information

The strength of cloud technology is also the very same characteristic that makes
it vulnerable to data breaches. The information contained within medical records may be
subjected to theft or other violations of privacy and confidentiality. Fortunately,
safeguards may be put in place to minimize such threats such as encryption, proper data
disposal, and other security features.
2. Cloud Setup Seems Cumbersome
The transition from a traditional to an automated system might be difficult for
some members of health care organizations that may not be familiar with cloud
technology. This technology, however, will be adopted by more institutions in the future.
With proper education and illustration of its function, hesitant practitioners may be able
to see its advantages.
Health Informatics in the Philippines

Health informatics is the application of both technology and systems in a health care
setting. It has been loosely practiced in the Philippines since the 1980s. Practitioners who had
access to IBM (International Business Machines Corporation) compatible machines used word
processors to store patient information. Since then, significant milestones in health informatics
have occurred over the years, one of which is the Community Health Information Tracking
System (CHITS), a Linux, Apache. MySQL, PHP-based system released under the general
public license (GPL). CHITS was named finalist at the Stockholm Challenge 2006 and one of
top three e-government projects in the Philippines by the Asia Pacific Economic Cooperation
(APEC) Digital Opportunity Center (ADOC).

CHITS is an electronic medical record (EMR) developed through the collaboration of the
Information and Communication Technology community and health workers, primarily designed
for use in Philippine health centers in disadvantaged areas. It is currently utilized in 111
government health facilities. What used to be manually done, eg., looking up a patient's record
for four to five minutes, can now be executed within a couple of seconds. The implementation of
CHITS has indeed resulted in higher efficiency rate among health workers since more time can
be spent in providing patient care (Philippine Council for Health Research and Development,
2012).

Despite the development, health informatics in the Philippines still suffers from various
issues that hamper progress, one of these is the lack of interest in the field. Health informatics is
seen more as a novelty rather than as a profession. When professional and economic
constraints come into play, priorities shift towards clinical responsibilities at the expense of
health informatics as a discipline.

Another issue is that many decision-makers do not use the benefits of information
technology in the health sector. The large initial expenditure for a health information system
remains another barrier to the integration of IT in the Philippine health care system (Marcelo,
2012).

Key Points to Remember

 Health information technology (HIT) involves the development and management of

health information for improved health service delivery.
 The electronic health record (EHR) is the central component of the HIT infrastructure.
 Picture archiving and communication systems (PACS) and vendor neutral archives
(VNAs) are two widely used types of HIT that help health care professionals store and
manage patients' medical images.
 An efficient health interoperability ecosystem provides an information infrastructure that
uses technical standards, policies, and protocols to enable seamless and secure capture,
discovery exchange, and utilization of health information.
 The advantages of health informatics in the cloud are integrated and efficient patient
care and better management of data.
  Despite the development, health informatics in the Philippines still suffers from various
issues that hamper progress, such as the lack of interest in the field. Another issue is
that the benefits of information technology do not seem apparent to many decision-
makers in the health sector.

LESSON 5: Health Information Systems

Health Information Systems

Health informatics is the application of both technology and systems in a healthcare

setting. While health information technology focuses on tools, health information systems cover
the records, coding, documentation, and administration of patient and ancillary services.

Concerns about the cost and quality of health care are among the motivating factors why
health information systems are increasingly implemented across health industries all over the
world. The combination of elements in a health information system enables the provision of
more efficient and effective health care services. The components of a health information
system are correlated and translated into harmonious operations.

The health information system (HIS) cover different systems that capture, store,
manage, and transmit health-related information that can be sourced from individuals or
activities of a health institution. These include disease surveillance system, district level routine
information systems, hospital patient administration system (PAS), human resource
management information systems (HRMIS), and laboratory information system (LIS).

The information collected from a well-functioning HIS is very useful in policy making and
decision-making of health institutions and becomes the basis in creating program action. This
translates to efficient resource allocation at the policy level, and improvement of the quality and
effectiveness of health at the delivery level.

HIS should be sustainable, user-friendly, and economical. Health care personnel should
be educated on the use of the routine data collected from the system and the significance of
good quality data in improving health (Pacific Health Information Network, 2016).

Role and Function of Health Information Systems

Sheahan (2017) defines health Information system (HIS) as a mechanism which keep track
of all data related to the patient such as patient's medical history, contact information,
medication logs, appointment schedule, insurance information, and financial account inducing
billing and payment. The roles that a well-implemented HIS can perform in improving health
services are follows:

1. Easier to files
The systems have revolutionized the collection and management of patient
information. The need for hard copy of the patient's medical records becomes optional
as the systems are electronic.
 2. Better control
Only authorized personnel can have access information on the patient's health.
Doctors may be given permission to update patient information while a receptionist may
only have the authority to update a patient's appointments.
3. Easier update
After creation of the record, patient information can be accessed and reviewed
any time and copies can be printed or released to the patient upon request.
4. Improved communication
HIS assist communication among doctors and hospital. However, medical
professional must adhere to regulation on patient privacy and security to ensure that
information is kept confidential and safe from unauthorized access.

A good health Information system delivers accurate information in a timely manner,

enabling decision-makers to make informed choices about the different aspects of the health
institution, from patient care to annual budgets. It also upholds transparency and accountability
due to easier access to information.

Components of Health Information Systems

The Health Metrics Network (HMN), in its Framework and Standard for Country Health
Information Systems (2008), defines health information systems as consisting of six
components.

1. Health information system resources

These include the framework on legislation, regulation, planning, and the
resources required for the system to be fully functional (e.g. personnel, logistics support,
financing, ICT, and the component's coordinating mechanisms).
2. Indicators
The basis of the HIS plan and strategy includes indicators and related targets
such as the determinants of health; health system inputs, outputs, and outcomes; and
the health status.
 3. Data sources
Data sources are divided into two main categories: (1) population-based
approaches such as civil registration, censuses and population surveys and (2)
institution-based data such as individual records, resource records, and service records.
Occasional health surveys, research and information produced by community-based
organizations may not be directly classified under the main categories, but they may
provide useful information.
4. Data management
Data management refers to the handling of data, starting from collection and
storage to data flow and quality assurance, processing compilation, and data analysis.
5. Information products
Data is transformed into useful information that serves as evidence and provides
insight crucial to shaping a health action.
6. Dissemination and use
HIS enhances the value of health information by making it readily available to
policymakers and data users.

These six components of health information systems can be categorized into inputs,
processes, and outputs.

Inputs refer to the health information system resources. These resources include health,
institutional coordination and leadership, health information policies, financial and human
resources, and infrastructures.

The indicators, data sources, and data management form the process in HIS. Core
indicators are needed as bases for program planning, monitoring, and evaluation. Population-
and institution-based sources are also essential for decision-making as they provide guide to
health service delivery. Importantly, these data must be accessible and understandable by
users and policymakers.

Outputs refer to the transformation of data into information that can be used for
decision-making and to the dissemination and use of such information.

Different Data Sources for Health Information Systems

Donaldson and Lohr (1994) explain that a comprehensive database for health
information systems include the following:
 1. Demographic data refers to the facts about the patient which include age and
birthdate, gender, marital status, address of residence, race, and ethnic origin.
Information on educational background and employment is also recorded along with
information on immediate family members to be contacted during emergency.
2. Administrative data includes information on services such as diagnostic tests or
out-patient procedures, kind of practitioner, physician's specialty, nature of institution,
and charges and рауments.
3. Health risk information records the lifestyle and behavior (e.g. use of tobacco
products or engagement in strenuous activities) of a patient and facts about his or
her family's medical history and other genetic factors. This information is used to
evaluate the patient's propensity for different diseases.
4. Health status refers to the quality of life that a patient leads which is crucial to his or
her health. This shows the domains of health which include physical functioning,
mental and emotional well being, cognitive functioning, and social functioning. It also
shows one's perception of his or her health in comparison with that of his or her
peers.
5. Patient medical history gives information on past medical encounters like hospital
admissions, pregnancies and live births, surgical procedures, and the like. It also
includes previous illnesses and family history (e.g. alcoholism or parental divorce).
6. Current medical management reflects the patient's health screening sessions,
diagnoses, allergies (especially on medications), current health problems,
medications, diagnostic or therapeutic procedures, laboratory test, and counseling on
health problems.
7. Outcomes data presents the measures of aftereffects of health care and of various
health problems. These data usually show the health care events (e.g. readmission
to hospital, unexpected complications or side effects) and measures of satisfaction
with care. Outcomes directly reported by the patient after treatment will be most
useful.

Key Points to Remember

 Health information systems (HIS) refer to systems that capture, store, manage and
transmit health related information that can be sourced from individuals or activities of
health institutions.
 HIS improves the delivery of health services because it ensures easier file access, better
control, easier update, and improved communications.
 The components of health information systems are health information system resources
(inputs): indicators, data sources, and data management (processes); and
transformation of data into information, and its dissemination and use (outputs).
 The different data sources are demographic data, administrative data, health risk
information, health status, patient medical history, current medical management, and
outcomes data.
LESSON 6: Health Management Information System

Health Management Information System

Traditionally, health care administrations have been managed manually, starting from
patient registration to consultation. The creation of documents proved o be time-consuming and
posed the risk of having duplicate records. Improper storage of these documents was also a
concern because of difficulty in retrieval and the high cost of maintaining proper storage. Getting
an overview of the number of patients visiting the hospital, or consolidating the nature of
problems that need immediate action, and providing pertinent reports were very difficult to
achieve. Tools such as snapshots and dashboard which are necessary in the analysis of the
performance of hospitals were unavailable.

Hospitals using the traditional manual process do not have real-time data and delays the
receipt of data pose a challenge to evidence-based program management. Accurate and real-
time records of equipment and drugs could not be obtained in a timely manner resulting in
problems in accountability, monitoring of expiry dates, stocks, and auto indenting. Inventory of
medicine and equipment was a tedious task due to lack of standards in filling names and codes
in the institution.

The need to enhance the management of health care services and to have real-time
data to monitor the hospital performance thus calls for a health information management system
that will address these concerns.

As defined by the World Health Organization (2004), health management information

system (HMIS) is "specially designed to assist in the management and planning of health
programmes, as opposed to delivery of care." The health component of HMIS refers to clinical
studies to understand medical technologies, clinical procedures, data base processes;
management refers to the principles that help administer the health care enterprise; and
information system refers to the ability to analyze and implement applications for efficient and
effective transfer of patient information. An HMIS is one of the six building blocks essential for
health system strengthening. It is a data collection system specifically designed to support
planning, management, and drugs decision-making in health facilities and organizations.

HMIS is a set of integrated components and procedures organizesd with the objective of
generating information that will improve health care management decisions math all levels of
the health system. It is a routine monitoring the system that evaluates the process with the
intention of providing warning signals through the use of indicators. At the health unit level,
HMIS is used by the health unit in-charge and the Health Unit Management Committee to plan
and coordinate health care services in their catchment area.

HMIS was developed within the framework of the following concepts (Republic of
Uganda Ministry of Health Resource Centre, 2010):

 The information collected is relevant to the policies and goals of the health care
institution, and to the responsibilities of the health professionals at the level of collection.
 The information collected is functional as it is to be used immediately for management
and should not wait for feedback from higher levels.
  Information collection is integrated for there is one set of forms and no duplication of
reporting.
 The information is collected on a routine basis from every health unit.

Roles of HMIS

The major role of HMIS is to provide quality information to support decision-making at all
levels of the health care system in any medical institution. In addition to encouraging the use of
health information in hospitals, it also aims to aid in the setting of performance targets at all
levels of health service delivery and to assist in assessing performance at all levels of sector
(Republic of Uganda Ministry of Resource Centre, 2010).

An HMIS needs to be complete, consistent, clear, simple, cost-effective, accessible, and

confidential (Janneh, 2002). It should be complete with all information but avoiding duplication
and consistent in assigning definitions to similar information from various sources. It should also
be simple to use and clear as to what is measured by the elements. The eligible users must
have access and should be able to use the system with ease. The confidentiality of patient
information and data privacy should always be a top priority. While providing all these benefits,
the system must prove its cost-effectiveness through its operations.

Functions of HMIS

The information from an HMIS can be used in planning, epidemic prediction and
detection, designing interventions, monitoring, and resource allocation (Republic of Uganda
Ministry of Health Resource Centre, 2010).

Historically, all information systems, including HMIS, are built upon the conceptualization
if three fundamental information-processing phases: data management, and data output. Each
phase comes with elements (Tan, 2010) that perform specific functions.

1. Data Input includes data acquisition and data verification.

a. Data acquisition refers to the generation and collection of data through the input
of standard coded formats (e.g., bar codes) to assist in the faster mechanical
reading and capturing of data.
b. Data Verification involves data authentication and validation. The authority,
validity, and reliability of the data sources help ensure quality of gathered data.
2. Data management, also called processing phase, includes data storage, data
classification, data update, and data computation.
a. Data storage includes preservation and archiving of data. It is advisable that
data which are no longer actively used should be archived. At times, it is
mandatory and part of legislation.
b. Data classification is also called data organization which sets the efficiency of
the system. Key parameters should be used for data classification schemes for
easier data search.
 c. Data computation requires various forms of data manipulation and data
transformation (e.g., mathematical models, linear and nonlinear transformation,
statistical and probabilistic approaches, and other data analytic process). This
function allows data analysis, synthesis, and evaluation so that data can be used
not only for decision-making but also for other tactical and operational use.
d. Data update facilitates new and changing information and requires constant
monitoring. For HMIS, the mechanism for data maintenance must be in place for
updating changes for manual or automated transactions.
5. Data output includes data retrieval and data presentation.
a. Data retrieval pertains to the processes of data transfer and data distribution.
The transfer process consider the duration of transmittal of required data from
the source to the appropriate criterion.
b. Data presentation is the reporting if the interpretation of the information
produced by the system. Summary tables and statistical reports are expected but
the use visuals is encouraged especially for high-level managerial decision-
making because they provide a better intuitive perspective of the data trend.

List of Functions of HMIS

Listed below are the possible functions in an HMIS with the corresponding type of
information that can be captured and tracked in the system (Behavioral Health Collaboration
Solutions, 2006).

1. Client data relates to all the information of the client which is related to his or her
transactions, reports, and other information such as client billing data, clinical data l, and
other client data.
2. Scheduling is observed to distribute resources to areas that need them. An example is
linking the schedule to the billing of the entity.
3. Authorization tracking focuses on monitoring of the authorized personnel and their use
of the authorized unit.
4. Billing refers to the notification of the charges for the patient and other related
documents such as the compliant electronic claim.
5. Accounts receivable (A/R) management ensures that costumers are properly notified
about their bill and will settle it accordingly. Data for A/R management include tracking
aging of unpaid services, tracking reasons for denials, and aged receivable report by
payer source.
6. Reporting refers to reports issued by the entity which could be basic reports or report
writer.
7. Medical record, also called electronic health record (EHR), is a collection of digital
information about a patient. Aside from patient registration, the data could include
assessment, treatment plan, and progress/encounter notes.
8. Compliance refers to procedure that should be followed for the improvement of the
condition of the patient or the service provided such as treatment plan and progress note.
 9. Financial data refers to information relating to the performance of the entity collected for
administering purposes. These include financial reports, general ledger, payroll, and
accounts payable.

Determinants of HMIS Performance Area

The determinants affecting the performance of an HMIS may be behavioral,

organizational, and technical.

Behavioral determinants

The data collector and users of the HMIS need to have confidence, motivation, and
competence to perform HMIS tasks in order to improve the routine health information system
(RHIS) process. The chance of the task being performed is affected by the individual
perceptions on the outcome and the complexity of the task (Aqil, Lippeveld, & Hozumi, 2009).
Lack of motivation and enough knowledge on the use of the data has been found to be a major
drawback in the data quality and information use. Changing people's attitude towards data
collection and analysis is necessary in order to maximize the performance of the RHIS process
(Routine Health Information Network, 2003).

Organizational determinants

The important factors that affect the development of the RHIS process are the structure
of the health institution, resources, procedures, support services, and the culture within the
organization (Aqil, Lippeveld, & Hozumi, 2009). However, other factors which include lack of
funds, human resources, and management support contribute to the determinant of the RHIS
process.

Having a system in place which supports data collection and analysis and transforms it
into useful information will help in promoting evidence-based decision-making. Thus, all
components within the system are ideal in making the RHIS perform better. And improved RHIS
performance means an effective organizational culture that promotes information use by
collecting, analyzing, and using information to accomplish the organization's goals and mission
(Sanga, 2015).

Technical determinants

Technical factors involve the overall design used in the collection of information. It
comprises the complexity of the reporting forms, the procedure set forward in the collection of
data, and the overall design of the computer software used in the collection of information
(Sanga, 2015).
PRISM Framework

The Performance of Routine Information Systems Management (PRISM) is a

conceptual framework that broadens the analysis of HMIS or RHIS by including the three
determinants of HMIS performance, namely:

 Behavioral determinants - knowledge, skills, attitudes, values, and motivation of the

people who collect and use data,
 Organizational/environmental determinants - information culture, structure, resources,
roles, and responsibilities of the health system and key contributors at each level, and
 Technical determinants - data collection processes, systems, forms, and methods.

This framework identifies the strengths and weakness in certain areas, as well as the
correlation among these areas. This assessment aids in designing and prioritizing interventions
to improve RHIS performance, which in turn improves the performance of the health system.

The PRISM framework founded on performance improvement principles, defines the various
components of the routine health information system and their linkages to produce better quality
data and continuous use of information, leading to better health system performance and,
consequently, better health outcomes (Aqil, Lippeveld, & Hozumi, 2009).

Key Points to Remember

 A health management information system (HMIS) is "specially designed to assist in the

management and planning of health programs, as opposed to delivery of care (WHO,
2004)."
 The major role of HMIS is to provide quality information to support decision-making at all
levels of the health care system in any medical institution.
 Historically, all information systems, including HMIS, are built upon the conceptualization
of three fundamental information-processing phases: data input, data management, and
data output. Each phase comes with elements that perform specific functions. The eight
elements are data acquisition, data verification, data storage, data classification, data
computation, data update, data retrieval, and data presentation.
 The determinants affecting HMIS performance are behavioral, organizational, and
technical.
 The PRISM (Performance of Routine Information Systems Management) framework
defines the various components of the routine health information system (RHIS) and
their linkages to produce better quality data and continuous use of information, leading
to better health system performance and consequently, better health outcomes.
LESSON 7: HMIS Monitoring and Evaluation

HMIS Monitoring and Evaluation

A health management information system aims primarily at assisting in the planning and
management of a national health strategy plans; thus, continuous monitoring and evaluation is
necessary for it to be effective. By definition and function, monitoring and evaluation are
complimentary. Monitoring refers to the collection, analysis, and use of information gathered
from programs for the purpose of learning from the acquired experiences, accounting the
resources used both internal and external, and obtaining results and making decisions. These
purposes correspond to three functions: learning, monitoring, and steering. Meanwhile,
evaluation is the systematic assessment of completed programs or policies. The objective is to
gauge the effectiveness of the program so that the adjustments can be made in areas that need
improvement. An evaluation has both a learning function in which the lessons learned need to
be incorporated into future proposals, and a monitoring function which means that the
concerned parties review the implementation of policy based on the objectives and resources.

Purpose of M&E

A robust monitoring and evaluation (M&E) system is required to access the effect of an
integrated service delivery. Appropriate indicators, data collection systems, and data analysis to
support decision-making help guide the successful implementation of integrated services and
measure the effect on both service delivery and use of service (FP/Immunization Integration
Working Group, n.d.).

M&E Framework

A general framework of M&E of health system strengthening (HSS) was developed by

various global partners and countries. Derived from the Paris Declaration on aid harmonization
and effectiveness and the International Health Partnership (IHP+), this framework places health
strategy and related M&E processes of each country at the center. The strengthening of a
common country platform for the M&E of HSS is the core of the framework. In doing so, there is
better alignment and the monitoring of fundings for health systems is easy.

There are four components of the framework as provided by WHO, namely, the indicator
domains, data collection, analysis and synthesis, and communication use, intended for
achieving greater health impact. For monitoring medical services, indicators should be tracked
to assess processes and results associated with the various indicator domains. In this way, the
strengths and weaknesses of implementation are provided and can be used for troubleshooting
in the system. In terms of outcomes and impact indicators, the changes may not be directly
caused by service delivery efforts for there are other factors to consider. However, these data
are still useful in understanding the current health status and context within a country
(FPI/Immunization Integration Working Group, n.d.).
 It should be noted that shifts in outcome and impact indicators may not be directly
attributable to integrated service delivery efforts, as there are many other factors which
influence these indicators. However, where possible, it can be useful to collect these data in
order to understand the broader health context within a country, and the ways in which
packages of interventions can lead to impact over time (FPI/Immunization Integration Working
Group, n.d.).

M&E Plan

An M&E plan addresses the components of the framework and establishes the
foundation for regular reviews during the implementation of the plan for the national level. Local
M&E systems generate information for global monitoring based on the health sector review
processes which are considered key factors in monitoring the progress and performance of the
entire system. Medical institutions are monitored and evaluated through the assessment of
reports, surveys, HMIS, and other evaluation studies.

Specifically, the National Health Mission of India identifies strategies which help in the
successful implementation of the framework. The framework should (1) be localized, (2)
address the needs for multiple users and purposes, (3) facilitate the identification of indicators
and data sources, and (4) be able to use the M&E in disease-specific programs.

M&E and HMIS Indicators

An indicator is a variable which measures the value of the change in units that can be
compared to past and future units. The focus is on a single aspect of a program such as input,
output, among others. HMIS uses various indicators to monitor key aspects of health system
performance. The United States Agency for International Development (USAID) classifies these
indictors (Table 7.1) into five broad categories, namely, reproductive health, immunization,
disease prevention and control, resource utilization, and data quality.

Table 7.1 Categories of HMIS Key Indicators

Key Performance Area Key Indicator

1. Family planning acceptance rate
2. Antenatal care coverage
3. Proportion of deliveries attended by
Reproductive Health
skilled health personnel
4. Proportion of deliveries attended by
HEW‟s
5. DPT-3 (Pentavalent-3) coverage (>1
child)
Immunization
6. Measles Immunization coverage (>1
child)
Disease Prevention and Control 7. Malaria case fatality rate among
 patients under 5 years of age
8. New malaria cases per 1,000
population
9. New pneumonia cases among children
under 5 per 1,000 population of < 5 yrs
10. TB cases detection rate
11. TB cure rate
12. Clients receiving VCT services
13. PMTCT treatment completion rate
14. PLWHA currently on ART
15. Trace drug availability (in stock)
16. OPD attendance per capita
Resource Utilization
17. In-patient admission rate
18. Average length of stay (in-patient)
19. Bed occupancy rate
Data Quality 20. Reporting completeness rate
21. Reporting timeliness rate
Source: HMIS Information Use Training Manual (USAID, 2013)

Table 7.2 provides specific indicators, data sources, and purposes for tracking each
indicator for monitoring family planning and immunization service delivery and assessing the
integration of services. This table includes a variety of quantitative indicators coupled with
qualitative techniques in order to better understand the basics of the integration processes and
solicit feedback on the approach.

Table 7.2 Quantitative indicators for monitoring family planning/immunization integration

Indicator Data Source Purpose

INPUTS
Vaccines stockouts in a single
month (YES/NO, by the type HMIS, Service statistics Monitor vaccine stockouts.
of vaccine)
Contraceptive stockouts in a
Monitor contraceptive
single month (YES/NO, by HMIS, Service statistics
stockouts.
type of contraceptive)
Monitoring reach of EP/FP
Number of service providers
integration training as an input
trained in provision of EPI/FP Training records
for effective integrated service
integrated services
delivery.
OUTPUS
Number of service delivery
Service statistics and Coverage of integrated
points offering integrated FP
Supervision service delivery
and immunization services
Number of days per month Service statistics and Availability of co-located
when both immunization and Supervision (Observation + FP/immunization services
family planning services are Interviews)
offered at the same site
Supplemental tracking column
Number/percent of women
that can be added to existing
attending routine child Quality/continuity of
immunization register
immunization services who implementation of integrated
[Monitored for
received information on family service delivery
demonstration/pilot programs
planning from a vaccinator
only]
Number/percent of women
Supplemental tracking column
(with children <12 months)
added to FP Ledger Quality/continuity of
going for family planning who
[Monitored for implementation of integrated
receive information on
demonstrations/pilot programs service delivery
immunization from the family
only]
planning provider
Number/percent women Supplemental tracking column
attending routine child added to Immunization Ledger
Acceptance of FP referrals
immunization services who [Monitored for
provided by the vaccinator
accept a referral to family demonstration/pilot programs
planning services only]
Comparison of supplemental
tracking column added to
Number/percent of women
immunization ledger, and
attending routine
supplemental tracking column Follow through on FP referrals
immunization services who
added to FP ledger provided by the vaccinator
follow through on a FP referral
[Monitored for
from a vaccinator
demonstration/pilot programs
only]
Comparison of supplemental
Number/percent of women tracking column added to FP
attending family planning ledger, and supplemental Follow through on
services who follow through tracking column added to immunization referrals
referral to immunization immunization ledger provided by the family
services from a family [Monitored for planning provider
planning provider demonstration/pilot programs
only]
OUTCOMES
Number of children receiving Immunization ledger/HMIS,
Use of immunization services,
DTP 1, DTP 3, measles1, and and population-based survey
dropout
DTP 1-3 dropout data
Percentage of children <12
Immunization coverage for HMIS and population-based months in a given population
DTP1, DTP3, and measles1 Survey Data who have received DTP1 and
DTP3
Number of new family Family Planning ledger/HMIS Uptake of family planning
planning acceptors by method services
type and demographic/age
group
Contraceptive use within a
Contraceptive prevalence rate Population Survey Data
given population
Cost of inputs required for
Total financial cost of inputs
integration. This may be
required to integrate FP and
Programs data/Special helpful in planning for
immunization services (per
costing studies decisions related to
facility, per client exposed, per
sustainability and scale-up
new FP acceptor)
integrated services.
IMPACT
Maternal, infant, and child Studies on maternal and Measure improvement in
mortality rates infant mortality health status.
1
In many countries measles coverage is higher than DTP3 coverage, even though measles is supposed to be given
later. Analysis and interpretation of findings for measles coverage should be done within the context of individual
country circumstances.

Source: Key Considerations for Monitoring and Evaluating Family Planning and Immunization Integration
Activities (FP/Immunization Integration Working Group, n.d.)

HMIS Indicators and Health Programs

HMIS is a source of routine data necessary for monitoring different aspects of various
health programs implemented in a country. The HMIS indicators should be carefully selected to
meet the essential information necessary for monitoring the performance of various health
programs and services and to present an overview of available health resources.

This section explains the relationship of HMIS indicators and some of the health
programs on communicable and non-communicable diseases. This disease data provide an in-
depth understanding of how HMIS can be used for monitoring program performance and how it
encourages similar in-depth analysis for all health programs and services such as maternal
survival intervention, child mortality and child survival intervention, and Stop TB program.

Maternal Survival Interventions

The fifth millennium development goal targets to reduce the maternal mortality ratio by
75 percent and to achieve universal access to reproductive health. Despite this goal, none of
the maternal survival intervention alone can reduce the maternal mortality rate. As Campbell
and Graham (2006) explained, the complexity of the country contexts and maternal health
determinants makes it complicated to choose the best strategies in achieving this goal. However,
they found that packaging of health facility-oriented interventions is highly effective and has high
coverage of the intended target group.
 In order to routinely monitor the progress towards implementation of a highly effective
package of maternal survival interventions, HMIS is designed to provide some of the core input,
process, and output indicators.

The HMIS indicators are related to the following:

1. Pregnancy care interventions

 1st antenatal care attendances
 4th antenatal care attendances
 Cases of abnormal pregnancies attended at out-patient departments (OPD)
of health facilities
 Institutional cases of maternal morbidity and mortality due to antepartum
hemorrhage (APH), hypertension and edema reported by in-patient
departments (IPD) of health facilities
 Cases of abortion attended at health facilities
 Cases of medical (safe) abortions conducted at health facilities

2. Intrapartum care
 Deliveries by skilled attendants (at health facilities)
 Deliveries by health extension workers (HEW) (at home of health posts)
 Institutional cases of maternal morbidity and mortality due to obstructed labor

3. Postpartum care
 1st postnatal care attendance
 Institutional cases of maternal morbidity and mortality due to postpartum
hemorrhage (PPH) and puerperal sepsis
4. Interpartum care
 Family planning method acceptors (new and repeat)
 Family planning methods issues by type of method

These indicators, although not complete to monitor all aspects of maternal survival
strategies, capture data related to pregnancy, such as intrapartum and postpartum care, and
are sufficient to give a broad indication of the performance of the package of maternal survival
interventions. More so, using these indicators help prompt further investigations when problems
on issues arise.

Child Mortality and Child Survival Interventions

The leading cause of under-5 child mortality in the Philippines in 2012, as reported by
the Department of Health (DOH) in its top 10 leading causes of child mortality report, was
pneumonia with 2,051 reported cases. Figure 7.1 shows data on other causes of child mortality,
such as diarrhea and gastroenteritis, congenital anomalies, septicemia, other diseases of the
nervous system, accidental drowning and submersion, dengue fever and dengue-hemorrhagic
fever, chronic lower respiratory diseases, meningitis, and leukemia.
 The Philippine government through DOH launched various strategies to help ensure
good health of Filipino children by 2025.

1. Child 21 – Child 21 or the Philippine Natal Strategic Framework for Plan

Development for Children 2000 to 2025 serves as a framework for policymaking and
program planning and as a roadmap for interventions at safeguarding the welfare of
Filipino children. This is part of the Philippines‟ commitment to the United Nations
Convention on the Rights of the Child (UNCRC).
2. Children’s Health 2015 – This is a subdocument of Child 21 which focuses on the
development of Filipino children and the protection of their rights by utilizing the life
cycle approach.
3. Integrated Management of Childhood Illness (IMCI) – IMCI is a strategy that aims
to lower child mortality caused by common illnesses.
4. Enhanced Child Growth – This is an intervention aimed to improve the health and
nutrition of Filipino children by operating community-based health and nutrition posts
all throughout the country.

Stop TB Program

Envisioning a tuberculosis-free world, the goal of the Stop TB Program (STP) is to

dramatically reduce the global burden of tuberculosis (TB) by 2015. This is in line with the
WHO‟s millennium development goals and the Stop TB Partnership which aims to push TB up
the world political agenda. One of the main objectives of the program is to achieve universal
access to high-quality care (i.e., universal access to high quality diagnosis and patient-centered
treatment) for all people with TB (including those co-infected with HIV and those with drug-
resistant TB).

TB case detection and successful completion of the treatment/cure of TB remain at the

core of the Stop TB Strategy. Thus, by 2050, one of the targets of the strategy is to reduce the
prevalence of and deaths due to TB by 50 percent compared with the 1990 baseline.

The HMIS indicators to monitor Stop TB Program are

 TB patients on DOTS (Number of new smear-positive pulmonary TB cases

enrolled in the cohort)
 TB case detection (Number of new smear-positive pulmonary TB cases detected,
number of new smear-negative pulmonary TB cases detected, number of new
extra-pulmonary TB cases detected)
 HIV-TB co-infection (Proportion of newly diagnosed TB cases tested for HIV)
 HIV+ new TB patients enrolled in DOTS
 TB treatment outcome (Treatment completed PTB+, Cured PTB+, Defaulted
PTB+, Deaths PTB+)
Key Points to Remember

 Monitoring and evaluation (M&E) is a core component of current efforts to scale up for
better health. Global partners and countries have developed a general framework for
M&E of health system strengthening (HSS).
 The primary aim of HMIS is to have a strong M&E and review system in place for the
national health strategic plan that comprises all major disease programs and health
systems.
 There are different HMIS indicators which can be used in monitoring the key aspects of
the health system performance. These are from among the five broad categories,
namely, reproductive health, immunization, disease prevention and control, resources
utilization, and data quality.
 HMIS is a source of routine data necessary for monitoring different aspects of various
health programs implemented in a country. The HMIS indicators should be carefully
selected to meet the essential information necessary for monitoring the performance of
various health programs and services and to present an overview of the available health
resources.

LESSON 8: HMIS Data Quality

Data Quality

Over the years, data quality has become a major concern for large companies especially
in the areas of customer relationship management (CRM), data integration, and regulation
requirements. Aside from the fact that poor data quality generates costs, it also affects
satisfaction, company reputation, and even the strategic decisions of the management.

Data quality is the overall utility of a dataset(s) as a function of its ability to be

processed easily and analyzed for a database, data warehouse, or data analytics system.

Aspects of Data Quality

 accuracy  reliability
 completeness  presentability
 relevance  accessibility
 consistency

Data quality signifies the data‟s appropriateness to serve its purpose in a given context.
Having quality data means that the data is useful and consistent. Data cleansing can be done to
raise the quality of available data (Rouse, 2005).

Lot Quality Assurance Sampling (LQAS)

Lot Quality Assurance Sampling (LQAS) is a tool that allows the use of small random
samples to distinguish between different groups of data elements (or lots) with high and low
data quality. For health managers and supervisors, using small samples makes the conduct of
surveys more efficient. This tool has been widely applied in the health care industry for decades
and has been primarily used for quality assurance of products.

The concept and application of LQAS have been adopted in the context of District Health
Information System (DHIS) data quality assurance. The adaptation was comprised of
designating health facilities, monthly reports, sections of monthly reports, and group of data
elements as „lots‟ to provide representative samples for data quality assurance of DHIS.

Steps in applying LQAS

1. Define the service to be assessed (e.g., DQA of DHIS).
2. Identify the unit of interest (e.g., supervisory area, facility, hospital, a district).
3. Define the higher and lower thresholds of performance based on prior information about
the expected performance of the region of interest.
4. Determine the level of acceptable error.
5. Determine the sample size and decision rule for acceptable errors to declare an area as
performing “below expectations.”
6. Identify the number of errors observed (mismatched data elements will be reliably
determined if the facility is performing above or below expectations).

Routine Data Quality Assessment (RDQA)

The Routine Data Quality Assessment (RDQA) tool is simplified version of the Data
Quality Audit (DQA) tool which allows programs and projects to verify and assess the quality of
their reported data. It also aims to strengthen data management and reporting systems.

The objectives of RDQA are as follows (RDQA User Manual, 2015):

1. Rapidly verify the quality of reported data for key indicators at selected sites.
2. Implement corrective measures with action plans for strengthening data
management and reporting system and improving data quality.
3. Monitor capacity improvements and performance of data management and reporting
system to produce quality data.

The RDQA is a multipurpose tool that is most effective when routinely used. Following
are the uses for the RDQA tool (RDQA User Manual, 2015):

RDQA Use Case Example

Routine data quality checks can be included in
Routine data quality checks as part of on-
already planned supervision visits at the
going supervision
service delivery sites.
Repeated assessments (e.g., biannually or
annually) of a system‟s ability to collect and
Initial and follow-up assessments of data
report quality data at all levels can be used to
management and reporting systems
identify gaps and monitor necessary
improvements.
 Monitoring and evaluation (M&E) staff can be
trained on the RDQA and sensitized to the
Strengthening of the program staff‟s capacity
need to strengthen the key functional areas
in data management and reporting
liked to data management and reporting in
order to produce quality data.
The RDQA tool can help identify data quality
issues and areas of weakness in the data
Preparation for a formal data quality audit management and reporting system that would
need to be strengthened to increase readiness
for a formal data quality audit.
Such use of the RDQA for external
assessments could be more frequent, more
External assessment by partners of the quality
streamlined, and less resource intensive than
of data
comprehensive data quality audits that use the
DQA version for auditing.

Development Implementation Plan

An implementation plan is a project management tool that illustrates how a project is

expected to progress at a high level. It helps ensure that a development team is working to
deliver ad complete tasks on time (Visual Paradigm, 2009). It is also important in ensuring the
efficient flow of communication between those who are involved in the project so as to minimize
issues that would delay delivery of the project. It validates the estimation and schedule of the
project plan.

An implementation plan is developed through the following key steps (Smartsheet, 2017):

 Define goals/objectives. Address the question, “What do you want to accomplish?”

 Schedule milestones. Outline the deadline and timelines in the implementation
phase.
 Allocate resources. Determine whether you have sufficient resources, and decide
how you will procure those missing.
 Designate team member responsibilities. Create a general team plan with overall
roles that each team member will play.
 Define metrics for success. How will you determine if you have achieved your
goal?

Data Quality Tools

A data quality tool analyzes information and identifies incomplete or incorrect data.
Data cleansing follows after the complete profiling of data concerns, which could range
anywhere from removing abnormalities to merging repeated information.
 By maintaining data integrity, the process enhances the reliability of the information
being used by an organization. Usually, these data quality software products can share features
with master data management, data integration, or big data solutions.

Gartner (2017) explains how these data quality tools are used to address problems in
data quality:

 Parsing and standardization refers to the decomposition of fields into component parts
and formatting the values into consistent layouts based on industry standards and
patterns and user-defined business rules.
 Generalized “cleansing” is the modification of data values to meet domain restrictions,
constraints on integrity, or other rules that define data quality as sufficient for the
organization.
 Matching is the identification and merging of related entries within or across data sets.
 Profiling refers to the analysis of data to capture statistics or metadata to determine the
quality of the data and identify data quality issues.
 Monitoring refers to the deployment of controls to ensure conformity of data to business
rules set by an organization.
 Enrichment is the enhancement of the value of the data by using related attributes from
external sources such as consumer demographic attributes or geographic descriptors.

As data quality continues to become increasingly all-encompassing, data integration

tools are further developed to include data quality management functionality.

Application/Scope of Data Quality Tools

The first generation of data quality tools was characterized by dedicated data cleansing
tools designed to address normalization and reduplication. However, in the last 10 years, it was
observed that there is a generalization of Extract, Transform, Load (ETL) tools which allow the
optimization of the alimentation process. Recently, these tools started to focus on Data Quality
Management (DQM), which generally integrates profiling, parsing, standardization, cleansing,
and matching processes (Goasdue, Nugier, Duquennoy, and Laboisse, 2007).

Root Cause Analysis

A root cause analysis is a problem solving method that identifies the root causes of
problems or events instead of simple addressing the obvious symptoms. The aim is to improve
the quality of products and services by using systematic ways to address problems in order to
be effective (Bowen, 2011).
Techniques in Root Cause Analysis

Root cause analysis is among the core building blocks in the continuous improvement
efforts of an organization in terms of its operation dynamics, especially in the way it handles
information. However, root cause analysis alone will not produce any valuable results. The
organization should seek to improve at every level and in every department for this to work. The
analysis will help develop protocols and strategies to address underlying issues and reduce
future errors. Bowen (2011) suggests that “to address the root cause of a problem, one must
identify the problem and ask “why” five times to determine the proper strategies to address its
root cause.”

1. Failure Mode and Effects Analysis

The failure mode and effects analysis (FMEA) aims to find various modes of
failure within a system and addresses the following questions for execution:
a. What is the mode in which an observed failure occurs?
b. How many times does a cause of failure occur?
c. What actions are implemented to prevent this cause from occurring again?
d. Are these actions effective and efficient?

FMEA is used when there is a new product or process or when there are
changes or updates in a product and when a problem is reported through customer
feedback.

2. Pareto Analysis

The Pareto analysis uses the Pareto principle which states that 20 percent of the
work creates 80 percent of the results. It is used when there are multiple potential
causes to a problem. The Pareto chart was created using the Excel software. It lays
down the potential causes in a bar graph and tracks the collective percentage in a line
 graph to the top of the table. The reflected causes from the table should account for at
least eight percent of those involved in the analysis.

3. Fault Tree Analysis

The fault tree analysis (FTA) is used in risk and safety analysis. It uses boolean
logic to determine the root causes of an undesirable event. The undesirable result is
listed at the top of the tree and then all the potential causes are listed down to form
shape of an upside down tree.

4. Current Reality Tree

The current reality tree (CTR) is used when the root causes of multiple problems
need to be analyzed all at once. The problems are listed down followed by the potential
cause for a problem. By doing so, a cause common to all problems will appear.

5. Fishbone Diagram
 The fishbone diagram is also called the Ishikawa or cause-and-effect diagram.
The diagram looks like a fishbone as it shows the categorized causes and sub-causes of
a problem. This diagramming technique is useful in grouping causes (e.g., people,
measurements, methods, materials, environment, machines) into categories. Categories
could be the 4 Ms (manufacturing), the 4 Ss (service), or the * Ps (also service)
depending on the industry.

6. Kepner-Tregoe Technique
The Kepner-Tregoe technique breaks a problem down to its root cause by
assessing a situation using priorities and orders of concern for specific issues. The
various decisions that should be made to address the problem are then outlined. Then, a
potential problem analysis is made to ensure that the actions recommended are
sustainable.
7. Rapid Problem Resolution (RPR Problem Diagnosis)
Another technique for root cause analysis is the rapid problem resolution (RPR
problem diagnosis) which diagnoses the causes of recurrent problems by following the
three phases below:
 Discover – data gathering and analysis of the findings
 Investigate – creation of a diagnostic plan and identification of the root cause
through careful analysis of the diagnostic data
 Fix – fixing the problem and monitoring to confirm and validate that the
correct root cause was identified

Sustaining a Culture of Information Use

Choo, Bergeron, Detlor, and Heaton (2008) state that information culture affects
outcomes of information use. The information culture is determined by the following variables:
mission, history, leadership, employee traits, industry, and national culture. It can also be
shaped by cognitive and epistemic expectations which are influenced by the way tasks are
performed and decisions are made.

The result suggests that in order to have a sense of information attitudes and values,
managers should consider taking the pulse of information of their own organizations. The sets of
identified behaviors and values could account for significant proportions of the variance in
information use. Thus, management plays an important role in sustaining a culture of
information and should continuously work on maintaining and improving the quality of data and
information used in daily operations.

Key Points to Remember

 Data quality is the overall utility of a dataset(s) as a function of its ability to be processed
easily and analyzed for a database, data warehouse, or data analytics system.
  Lot Quality Assessment (LQAS) is a tool that allows the use of small random samples to
distinguish between different groups of data elements (or lots) with high and low data
quality.
 The Routine Data Quality Assessment (RDQA) tool is a simplified version of the Data
Quality Audit (DQA) which allows programs and projects to verify and assess the quality
of their reported data.
 The development of an implementation plan is important in ensuring that the
communication between those who are involved in the project will not encounter any
issues and work will also be delivered on time.
 A root cause analysis is a problem solving method aimed at identifying the root causes
of problems or events instead of simply addressing the obvious symptoms.
 Techniques in root cause analysis include failure mode and effects analysis (FMEA),
Pareto analysis, fault tree analysis (FTA), current reality tree (CRT), fishbone or
Ishikawa or cause-and-effect diagram, Kepner-Tregoe technique, and RPR problem
diagnosis.

LESSON 9: Hospital Information System

Hospital Information System

Health care plays a vital role in a society and people expect efficiency from health care
providers and health institutions which face the challenges of handling the numerous patients
that seek their services. Proper management of clinical and operational records is therefore
necessary. Presently, most hospitals have shifted from tedious manual recording to the use of a
hospital information system (HIS) to assist them in maintaining the different records of the
institutions.

Hospital information system (HIS) is a computer system structured to manage all the
records of health care providers to make available information and reports useful to health care
personnel in doing their job more efficiently. HIS was introduced in the 1960s and has evolved
since then to cope with the changes and demands of the modern times. Back then, the features
of HIS were used mainly for billing and inventory. However, all of these have changed through
time. Today‟s system is also integrated with other financial, scientific, and administrative
programs.

The modern HIS has applications built to address the needs of the various departments
of health facilities such as nursing, pharmacy, finance, radiology, and pathology. There are
hospitals with as many as 200 disparate system integrated into their HIS. Hospitals using the
HIS experience efficiency in accessing reliable patient information with just a few clicks.
However, advancements and new developments will be rendered useless if the system is not
user-friendly and training is inadequate.

While HIS delivers high quality patient care and better management of financial records,
it needs to be affordable, scalable, and centered on the needs of patients and medical
personnel. It should be adaptable to rapid technological changes. An effective HIS also provides
enhanced integrity of facts, minimization of transcription error and duplication of records, and
shorter turnaround times for reports.

HIS available today links computers that are capable of quickly optimizing operations
and delivering quality service. The system gather, process, retrieve patient information, and
provide hospital stakeholders with relevant information through reports for better decision-
making.

The system also guarantees delivery of information required by the health care
personnel because of the optimized core library. It can also be customized to consider the
particular needs of the departments and centralized them into the system. However, a hospital
should provide the requirements in detail to the HIS provider during the initial stages of scoping
so that its needs will be met and accurately provided. For example, the institution could ask that
the solution be based on RDBMS (relational database management system) or ask for a
multilingual interface for better handling of information (EMR Education Center, 2013).

HIS for Different Departments

1. Nursing Information Systems

Nursing information systems (NIS) are developed to enhance patient care by
providing nurses with accurate information to assist them in performing their duties more
efficiently. An NIS carries out numerous functions including the handling of personnel
schedules, accurate patient charting, and better clinical data integration.
Agenda packages help enhance the management of the workforce by helping
managers handle overtimes and absences. They can also be used to obtain cost-
effective staffing and show staffing levels. Patient charting applications allow better
analysis of critical signs. Nurses could check admission information, and care plans
along with applicable nursing notes. Crucial information is kept and can be retrieved
when needed. This is also useful in designing the patients‟ care plan since the medical
information integration function allows nurses to collect and examine retrieved medical
records.
2. Physician Information Systems
Physician information systems (PIS) are designed to improve the practice of
physicians. Electronic medical records (EMRs) and electronic health records (EHRs) are
some programs where PIS is deployed and extensively used. Most systems offer
support 24/7 to facilitate easier usage of the system by health care professionals.
3. Radiology Information Systems
Radiology information systems (RIS) are capable of providing billing services and
appointment scheduling aside from reporting and database storage. Technological
advances have made the practice of radiology more complicated such that more
hospitals turn to RIS to address the commercial concerns of their radiology departments.
4. Pharmacy Information Systems
Pharmacy institution systems (PIS) help monitor the utilization of medicines in
health institutions. The system also handles information on medication-related
 complications and drug allergies of patients. It provides information to identify drug
interactions which helps in administering the appropriate drugs by considering the
physiological conditions of the patient (EMPR Education Center, 2013).

Selecting a Hospital Information System

The following are the aspects needed to be considered in selecting an HIS (EMR
Education Center, 2013):

1. Total cost of package – HIS is available for all sizes and budgets. For hospitals with
smaller budgets, providers may reduce upfront and maintenance fees by using a design
that requires fewer servers and hardwares.
2. Web-based system – The system is available on the internet which means that
authorized personnel can access the information anywhere and anytime. It also allows
data sharing between hospitals. A hospital with updated patient history in its system can
facilitate access to information from other health facilities upon request.
3. Implementation and support – During the deployment or upgrade of the HIS, it is
imperative that the vendor provides ample training and assistance to the users of the
system. Consider vendors that offer 24/7 support through telephone or web services.

HIS Providers in the Philippines

BizBox

BizBox, Inc. was founded 25 years ago. Its very first hospital project was completed in
1994. The goal of the company is to improve work efficiency in health care institutions through
software systems, and to produce advanced solutions for better patient care.

Today, it is among the top IT companies in the health care industry. Aside from being a
certified Microsoft Fold Partner, it has also received the Independent Software Vendor (ISV) of
the Year Award. It has fully integrated systems such as electronic health records (EHR) and
document management system (DMS) that will streamline tasks and help provide better health
services (BizBox, 2017).

KCCI Medsys

Kaiser-dela Cruz Consulting, Inc. specializes in application development for hospitals,

industrial clinics, and medical-related educational institutions in the Philippines. Its products,
Visual MEDSYS for hospitals and MEDSCHO for schools, provide integrated, comprehensive,
and proven solutions for efficient health care practices.
Comlogik

Comlogik Business Systems, Inc. is a Philippine-based software development company

that was established in 1999, with a vision to be a global technology company. Comlogik led the
way in developing innovative applications like online hospital services in which patients can
access their billings and examination results, while administrators can access reports and
doctors can access patients‟ records anywhere and anytime.

HIS Functions

Help Desk, Scheduling, Patient Registration

Help desk

The help desk becomes more efficient through the HIS because the manual retrieval of
information is no longer needed. Clients are provided with information ad guidelines associated
with a company‟s or institution‟s products and services without any hassle.

Scheduling

Managers and employees can access work schedules from anywhere they are and
effectively discuss their scheduling preferences through the HIS. An employee scheduling
software helps save time and makes employee scheduling less difficult.

Patient Registration

The HIS patient registration form records the name, age, gender, marital status, and
other relevant information regarding the patient. These pieces of information are used for record
keeping and account management purposes. This form is usually filled out during the patient‟s
visit or consultation but if the patient is unable to complete the form due to the need for prompt
medical attention, the form can be filled out by a relative or guardian.
Admission, Discharge, and Transfer Procedures

Admission

Before a patient is admitted to a health facility, an admissions counselor will call him or
her to gather preliminary information, offer vital information concerning the hospital stay, and
answer questions if there are any. Additionally, the physician may also schedule recurring
medical exams, such as laboratory tests or X-rays, before hospitalization. Other routine tests
can also be carried out on the day of admission. All these can be done more efficiently through
the HIS.

Discharge

Through the HIS, instructions that accompany a patient‟s discharge or transfer are more
efficiently provided. These instructions may include discharge planning which details services
needed to be administered after the hospital stay to ensure the full recovery of the patient.
Transfer

The term “transfer” means movement (along with the discharge) of an individual outside
of the hospital premises at the instructions of any authorized hospital personnel. This, however,
does not encompass movement of an individual who (a) has been declared lifeless, or (b)
leaves the facility without the permission of any such authorized person (Louisiana State
University, 1993).

If a patient is transferred from the emergency room, employees must fulfill the statutory
requirements for a proper switch. With the HIS, patient transfer details are easily accessed and
processed.

Billing, Contract Management, and Package Deal Designer

Billing

Billing statements show all records pertaining to invoices, payments, and the current
balance of a patient‟s account. HIS is a very useful for patients who require frequent health care
services because numerous invoices can be combined and a lump sum payment can be made.
It is good practice to generate the billing statement on a regular basis so that the institution
could keep track of its collectibles. HIS lists the outstanding balances of the patients. Any
overdue payments may be checked easily. In addition, balances of patients who only have
minimal transactions are kept updated.
Contract Management

Goodrich (2013) defines contract management as the process of managing contract

creation, execution, and analysis to maximize the operational and financial performance of an
organization while reducing financial risk. Organizations constantly encounter pressure to
reduce costs and improve company performance. Contract management proves to be a very
time-consuming element of business, which facilitates the need for an effective and automated
contract management system.

When a contract management strategy is successfully implemented, organizations can

expect to see the following:

 realization of expected business benefits and financial returns

 cooperation and responsiveness of the supplier to the organization‟s needs
 no contract disputes or surprises
 satisfactory delivery of services to both parties

Package Deal Designer

Posting diagnostic medical packages for in-patients, out-patients, and emergencies

requires the same process; the difference is that for emergencies, this is called post-diagnostic
package deal. HIS helps in accessing information regarding package deals without going
through hassle of paperwork.

Laboratory, Radiology, and Cardiology Reporting

Laboratory Reporting

Despite differences in presentation and form, all laboratory reports must possess
common elements as required by institutional and company policies. They may also contain
supplementary items not specifically required, but which the laboratory chooses to report to aid
in the interpretation of results of medical testing (American Association for Clinical Chemistry,
2017).

For identification and filing purposes, some laboratory reports display elements with
administrative or chemical information such as the following:

 Patient name and identification number or a unique patient identifier and

identification number
 Name and address of the laboratory location where the test was performed
 Date when report was printed
 Test report date
 Name of doctor or legally authorized person ordering the test(s)

Information about the specimen and the test itself, such as those included below, are
other elements that make a laboratory report more meaningful:

 Specimen source (if applicable)

 Date and time of specimen collection
 Laboratory accession number
 Name of the test performed
 Test results
 Abnormal test results
 Critical results
 Units of measurement (for quantitative results)
 Reference intervals (or reference ranges)
 Interpretation of results
 Condition of specimen
 Deviations from test preparation procedures
 Medications, health supplements, etc. taken by the patient

Radiology Reporting

According to the University of Virginia (2013), a radiology report is an official medical

document that provides the details of the requested radiology examination and the procedure
conducted by the radiologist. A qualified physician authorized by the health care institution
interprets the report. The main objective of the report is to address the queries in the request.
The findings in the report should take into account both positive and negative findings. Important
findings should be stated followed by incidental findings.

The basic sections of a radiology report enumerated the American College of

Radiology‟s practice guideline on communication must include administrative information,
patient identification, clinical history, imaging technique, comparison, observations, summary or
impression, and signature of the radiologist. The length of the report is dependent on the
complexity and cost of the examination.
Cardiology Reporting

Cardiology reports, like other laboratory reports, contain important medical information
based on the test results of the patient which are set against past medical records. Doctors are
able to write vascular reports much faster since access and retrieval of information are made
more convenient through computer systems.

Using the cardiology information system (CIS), vascular sonography reports are
accurately created with only a few clicks. Information on these reports could include ultrasonic
ultrasound and diagrams. Nowadays, physicians opt to provide automated reports through the
use of information systems. The medical staff can process laboratory reports for the approval of
the physician. This means that results are generated more efficiently which translates to
improved patient experience.

Materials Management System – Pharmacy, Main Stores, and Purchase

Materials management is primarily concerned with planning, identifying, purchasing,

storing, receiving, and distributing materials are in the right location when needed.

As such, the automation of an inventory or a materials management system is

necessary for a hectic health center to streamline the hospital supply chain. Computerized stock
management systems include technologies for tracking inventories and devices used each day
in a health care setting. Generally, they utilize barcodes and RFID tags with precise
identification numbers assigned for each inventory object to enable accurate tracking and
control. Automatic stock management systems also assist health care institutions in figuring out
whether merchandise has been recalled or damaged and should not be given to patients. They
enable isolation of drugs and devices that are used regularly and forecasts capacity shortages
(Pontius, 2018).

Virtually, every health care institution has a materials management department that is
accountable for receiving materials, retaining central stock, and delivering supplies within the
institution. Typically, this is where the responsibility of the materials management department
ends. An inspection of a nursing unit, suite, or exam floor will reveal a smaller, self -managed
inventory in supply closets, nurses‟ stations, and individual rooms. These inventories are
essential in maintaining supplies conveniently available for use.

Management Reporting

Today, management reporting is not limited to data retrieval. It has become a platform
for reporting information valuable to the institution. Recent technological advancements help
management reports to provide non-monetary information which enables the management to
have an oversight of its operations. In the same way, these advancements pave the way for the
emergence of management reporting systems. These systems capture the necessary data
required by management to operate more efficiently. With this, data redundancy and data
quality issues are minimized. Employee headcount, customer account information, funding, and
overall performance are some of the data that can be retrieved through the system. Thus, a
good management reporting system enhances the capability of an institution to be more
responsive, efficient, and effective in decision-making which affects the performance of the
institution as a whole. These systems offer a single holistic view which highlights high value
sources and eradicates the lack of visibility in reviewing the performance of the institution
(Kumar, 2017).

In-Built Tally Interface

Tally.ERP9 is a software that provides simplified solutions to operations in health

institutions such as registration, accounting, inventory management, tax management, among
others. Tally is easy to learn and can be implemented with minimum resources. It is reportedly
used by over 1,000,000 entities across the globe.

Key Points to Remember

 A hospital information system (HIS) is a fundamental computer system that could

manage all the information to permit health care providers to do their jobs efficiently.
 HIS for different departments are nursing information (NIS), physician information
system (PIS), radiology information system (RIS), and pharmacy information system
(PIS).
 The following should be considered during the selection of the HIS: total cost of the
package, web-based system, and implementation and support.
 The top 3 HIS providers in the Philippines are Bizbox, Inc., KCCI Medsys, and Comlogik.
 The function of HIS address the following concerns: help desk, scheduling, patient
registrations, admissions, discharge and transfer procedures, billing, contract
management, and package deals.
 Materials management is primarily concerned with the planning, identifying, purchasing,
storing, receiving and distribution of materials. Its purpose is to guarantee that the right
and sufficient materials are in the right location when needed.
 Management reporting systems help in capturing the data sets that are needed for
managers to run an effective enterprise.
LESSON 10: Laboratory Information Management System

Laboratory Information Management System

The laboratory information management system (LIMS) is designed to help process

information in medical research to improve the efficiency of the department‟s services and
laboratory operations by reducing manual tasks and procedures. For example, a LIMS records
information automatically which saves time and reduces typographical error. This is commonly
used in conjunction with laboratory information system (LIS) in the medical and pharmaceutical
industries.

According to Gartner‟s 2016 Hype Cycle for Life Sciences, most of the top
pharmaceutical laboratories use LIMS. The system is also useful for biobanks and genomic
testing centers and laboratories that study drugs and develop formulations. However, the health
care institution must consider the data capture process, storage, and retrieval in selecting the
solutions provider because some are more suitable than others (Reisenwitz, 2017).

Functional Requirements and Features of LIMS

According to Reisenwitz (2017), the functionality of LIMS includes sample management,

workflow management, reporting, electronic medical records (EMR)/electronic health records
(EHR), mobile, and enterprise resource planning (ERP).

Sample Management

Accurate and detailed records are necessary to make sure that samples are not lost or
mixed up. A record show whether the sample meets the acceptable values.

LIMS records and stores the following information about the sample:

 Who the sample was taken from?

 What is the sample taken?
 Who is working with it (researcher or provider)?
 Who handled the sample?
 Where does it go next?
 How do you store these samples?
 When does it need to move?

LMIS automates most of these by using radio-frequency identification (RFID) or

barcodes in recording and updating logs and track the chain of custody of the sample.
Workflow Management

LIMS can be used to automate records and workflows which saves time. Exiting coding
methods and procedures enable the system to take part in the decision process. Using present
rules, it can suggest instruments needed for the procedure and assign the medical laboratory
technician or specialist to complete the test.

Reporting

Using LIMS, reports can be run and exported to make them standard and customized.
Reports on the most frequently used instrument, the average handling time of sample, and list
of backlogs are useful in data analysis and formulation of recommendation for future
policymaking.

EHR

Some LIMS have a built-in-electronic health records (EHR) functionally which is capable
of handling patient records and billing information. A health institution should consider this
during acquisition because the feature will greatly help in managing clinical laboratory
procedures.

Mobile

Gartner‟s (2016) reports that mobile LIMS offerings are limited. But with the accepted
use of smartphones in the laboratory, it is better for LIMS to be mobile-friendly.

ERP

A LIMS that can handle inventory functions is recommended. The enterprise resource
planning (ERP) solution is especially useful in viewing current supplies, calculating storage
capacity, and managing location.

Core Components of LIMS

LIMS software suites usually involve multiple components to provide a variety of

functions for different levels of the laboratory. IEEE GlobalSpec (2015) specifies that
components of a LIMS software but are not limited to the following:

 Electronic laboratory notebooks

 Sample management programs
 Process execution software
 Records management software
  Applications to interface with analytical or data systems
 Workflow tools
 Client tracking applications
 Best practice and compliance databases
 ERP software

(View the complete components of a laboratory information management system in

McDowall‟s Risk Based Validation of Laboratory Information Management Systems.)

Laboratory Standards

To help promote laboratory safety, the Occupational Exposure to Hazardous Chemicals

in Laboratories Standard (29 CFR 1910.1450) was released in the United States by the
Occupational Safety and Health Administration (OSHA) in 2011.

Some important provisions from the standard are cited below:

Laboratory is a workplace where hazardous chemicals are used. It is also

a facility that stores small quantities of hazardous chemicals which are not
intended for production use. On the other hand, the laboratory use of hazardous
chemicals should meet the conditions listed below:

 The manipulation of chemicals should be on “laboratory scale” only

and can be handled by one person.
 There is the use of multiple chemicals and procedures.
 The procedures should not simulate any production process.
 Protective laboratory tools are available and proper practices are
followed to minimize potential exposure to harmful chemicals.
 Any hazardous use of chemicals which does not meet this definition
is regulated under other standards. Examples are
 chemicals used in the maintenance of the laboratory building,
 production for commercial scale, and
 testing of a product for quality control.

A Chemical Hygiene Plan (CHP) which discusses all aspects of the

laboratory standards should be formulated if the standards apply. The employer
must implement the provisions which address the proper purchase, storage,
handling, and disposal of the chemicals used in the facility.

The primary elements of a CHP include the following:

1. establishment of standard operating procedures (SOP) to minimize

exposure to chemicals and dissemination of information on the
requirements for personal protective equipment, waste disposal
procedures, and engineering controls;
 2. monitoring of the work environment to provide the action and medical
attention required for some chemicals;
3. statement of plan on how to obtain free medical care for work-related
exposures; and
4. designation of personnel who will handle CHP-related activities such
as handling data sheets, organizing trainings, monitoring adaptation,
and revising CHP if deemed necessary.

LIMS Application

Patient Registration

When a patient arrives at the hospital, the admission clerk will take some basic
information and will guide him or her to a registration window.

Billing

The process of generating SOAs (statement of accounts) or billing statements of in-

patients, out-patients, and emergencies are the same. In the following example, an in-patient‟s
billing statement is used.
Contract Management

Most LIMS allow the laboratory professionals to manage the billing and payment aspects
of their activities and to create statistical and billing reports on a par with the laboratory and
management needs. They provide parameters for a flexible price schedule and enable
heightened attention on customer needs. They automate billing processing, hasten collections,
and offer marketing tools which reduce the time spent on standard flow and allow billing and
accounting personnel to focus on improving collection of problematic accounts (Infomed, 2017).

In addition, the common features of LIMS for invoicing and contract management include:

 customer customizable invoices including history analysis of balance and charges,

history balance, detailed services, and participation when in insurance coverage,
discounts, among others;
 different electronic formats for invoices to allow interfacing with customer electronic
systems;
 customizable information completion reports for customers;
 managerial reports which display laboratory billing status for payer groups including
projected return values for each player group;
 ability to change the insurance organization of a patient per visit;
 ability to select which tests are covered by insurance and which have automatic
modification of the prices accordingly;
 supervision of financial data management of the sender;
 reminder for amounts due from past visits;
 immediate access to the billing card of each patient; and
 consistency with international laws.

Accounts Receivables

Through the integration of the LIMS, the personnel in charge of managing accounts
receivables can easily extract information which was already available from the invoicing and
contract management procedures. Additionally, the LIMS can

 generate specific or complete accounts receivable reports,

 monitor balances for reconciliation and audit purposes,
 export data to other accounting systems, and
 customize reports according to specifications.

Worklist and Workflow

LIMS assists laboratories in setting priorities of current workloads based on analyst and
instrument availability. This function allows the user to track a sample, a batch of samples, or
numerous batches through their lifecycle. Queuing can also be done by sample or by workflow
which is a block of repetitive procedures in a certain process. The queuing and work list feature
provides insights about when an event occurred, how long it was, and who was involved.

In addition, other features also enable personnel and workload management, thereby,
allowing uses to plan workload schedules and assignments, and employee information and
training. Ultimately, the worklist and workflow functions operate to facilitate more efficient
laboratory processes.

Quality Control

Diagnostic tests executed inside the clinical laboratory may yield two kinds of results, a
patient result or a quality control (QC) result. The result can be quantitative (in numbers), or
qualitative (positive or negative) or semi-quantitative (limited to a few different values). QC
results are used to verify whether or not the instrument is working within prescribed parameters.
Based on the said results, reliability of a patient‟s test results will be determined (Bio-Rad
Laboratories, 2008).

LIMS‟ functions enable users to set standards about the relevant range of patient test
results or to extract test result information for the purpose of quality assurance. Outliers and
deviations can be flagged, and appropriate warning signals can notify users about issues which
involve the quality of the samples or the equipment currently in use.

Barcode-generation, Printing, and Reading

LIMS modules are commonly linked to a barcoding label generator which enables a fast
and easy method to identify tubes, samples, documents, and many others. The code can simply
be printed on a label sticker to be placed on any item which needs identification. A barcode
editor also allows multiple labels to be printed at a label printer. The barcode series can usually
be customized to suit the organization‟s or classification needs. With this kind of technology,
information about a tube, a specimen, or equipment within the laboratory can be found and
retrieved effortlessly using a barcode scanner.

In-built Bi-directional Interfaces with Equipment

Figure 10.4 shows the interface of a bi-directional

equipment used in medical laboratories. A two-way
communication between the information system and the clinical
instrument is required. LIMS downloads the test orders and
specimen ID for each test. On the other hand, the clinical
instrument uploads the same information for analysis. The same
method is also used by instruments for microbiology,
hematology, and other areas.
Key Points to Remember

 A laboratory information management system (LIMS) is a software designed to make

laboratories more efficient and effective.
 The ultimate aim of a LIMS is to enhance efficiency in laboratory operations by reducing
manual procedures.
 The core components of LIMS are electronic laboratory notebooks, sample management
programs, process execution software, records management software, applications
interface, work flow tools, client tracking, best practice and compliance databases, and
ERP software.
 The US Occupational Safety and Health Administration (OSHA) released an
Occupational exposure to Hazardous Chemicals in Laboratories Standard (29 CFR
1910.1450) in 2011 to facilitate laboratory safety.
 LIMS covers registration, billing, contract management, and monitoring of accounts
receivable.
 LIMS assists laboratories in setting priorities of current workloads based on availability of
analysts and instruments.
 LIMS‟ functions enable users to set standards for the relevant range of patient test
results or to extract test result information for the purpose of quality assurance.
 LIMS modules are commonly linked to a barcoding label generator, enabling a fast and
easy method of identifying tubes, samples, documents, and many others. The label can
simply be printed on a sticker and be placed on any item which needs identification.
 A bi-directional interface application saves time in programming test orders into the
analyzer and eliminates errors in manual entry. This can result in a considerable
enhancement of analyzer productivity.